Routine inspection·August 14, 2025

On 08/14/25, 10:15 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Adam Syncheff, and reason for the visit was disclosed. Facility is licensed as a two-story building. Fire clearance approved for (130) non-ambulatory, of which, eight (8) may be bedridden. Hospice waiver for thirty (30). There are currently four (4) residents receiving hospice care services, and one (1) bedridden. At 10:40 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F. within the required range. The facility maintains approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted in July 2025. [LIC 809C -Continued]- Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested and is working properly. Fire drill last conducted July 2025. Fire Extinguishers observed as fully charged with service date of 3/05/2025. Fire suppression system (i.e. Sprinklers, Valve Controls, Main Drains, etc.) were inspected on 4/01/2025; Annual fire alarm equipment inspection shows PASSED results. Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed as maintaining required temperatures, appliances and fixtures functional, with a sufficient amounts of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near food areas. Commons: Activity room, dining room, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Due to time constraints, LPA was unable to complete this required annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator.